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Original Investigation |

A Retrospective Review of the Progression of Pediatric Vocal Fold Nodules

Heather C. Nardone, MD1; Thomas Recko, BA2; Lin Huang, PhD3; Roger C. Nuss, MD2
[+] Author Affiliations
1Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
2Department of Otolaryngology and Communication Disorders, Boston Children’s Hospital, Boston, Massachusetts
3Clinical Research Program, Boston Children’s Hospital, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2014;140(3):233-236. doi:10.1001/jamaoto.2013.6378.
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Published online

Importance  To our knowledge, the rate of change in the size of pediatric vocal fold nodules (VFNs) has not been investigated. Improved understanding of the factors that affect change in VFN size may help to better guide treatment decisions and counselling of families.

Objective  To characterize the rate of change in the size of pediatric VFNs over time and to identify which factors affect increased rates of improvement.

Design, Setting, and Participants  Retrospective review of 67 children evaluated in a voice clinic between 2002 and 2011 with a primary diagnosis of VFNs.

Exposure  No treatment or behavioral modification only (n = 19) vs targeted voice therapy with or without the treatment of associated conditions (gastroesophageal reflux and allergic rhinitis) (n = 45) vs surgical intervention (n = 3).

Main Outcomes and Measures  Change in VFN grade (graded according to a previously validated scale based on size) over time.

Results  Sixty-seven patients with a median (range) age of 6.0 (3.8-20.6) years were analyzed. Median (range) follow-up was 25 (1-119) months. The rate of change in VFN grade over time was significantly associated with large baseline VFN size (P < .001) and targeted voice therapy with or without the management of associated conditions or surgery (P = .01); the association with postpubescent age was not significant (P = .09). The rate of change in VFN grade was not significantly different at 1 and 3 years postbaseline (P = .33).

Conclusions and Relevance  Baseline VFN size, treatment, and patient age are important in predicting the rate of improvement in nodule size over time. Rate of change in VFN size is a gradual decrease that is steady over time. This information can be used to help guide treatment decisions and counsel families of children with VFNs regarding expectations for improvement. Additional study is needed to evaluate whether the same factors that influence nodule size similarly influence parental perception of voice and expert perceptual voice analysis.

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Figure 1.
Expected Resolution of Vocal Fold Nodules Over Time for Entire Study Population

Extrapolation showing the expected decrease over time for all children (N = 67).

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Figure 2.
Expected Effect of Baseline Vocal Fold Nodule (VFN) Grade, Treatment, and Age on Resolution of VFNs Over Time

Extrapolation comparing the expected decrease in VFN grade over time for children with large (grade 3; n = 39) and small (grade 1 or 2; n = 28) baseline VFNs (A), for children who were observed or underwent behavioral modification (n = 19) or received targeted voice therapy with or without the treatment of associated conditions (n = 45) (B), and for prepubescent (n = 60) and postpubescent (n = 7) age groups (C).

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